Clinical

Practice

Systematic Review of Periodontal Plastic Surgery in the Treatment of Multiple Recession-Type Defects
Leandro Chambrone, DDS, MSD; Luiz A. Lima, DDS, MSD, PhD; Francisco E. Pustiglioni, DDS, MSD, PhD; Luiz Armando Chambrone, DDS, MSD, PhD
Contact Author
Dr. L. Chambrone Email: chambrone@usp.br

ABSTRACT
Objectives: The objectives of this systematic review were (1) to evaluate results obtained with different periodontal plastic surgery procedures in the treatment of multiple recession-type defects and (2) to assess differences in results from randomized controlled trials and other types of studies (i.e., controlled clinical trials and case series). Materials and Methods: The MEDLINE, EMBASE and CENTRAL databases were searched up to June 2008 to identify randomized controlled trials, controlled clinical trials and case series with a follow-up period of at least 6 months for patients with multiple recession-type defects who were treated with periodontal plastic surgery. Results: Of 632 articles initially retrieved, only 16 were deemed suitable for more detailed analysis. Of these, only 4 case series met the inclusion criteria. Mean recession and clinical attachment level decreased substantially from baseline to final examination, and probing depth also declined. Mean width of keratinized tissue increased. Mean root coverage ranged from 94% to 98% over the 4 studies, and complete root coverage was achieved for 68% to 90% of patients in the 3 trials for which this variable was reported. Conclusions: Analysis of the limited information available in the dental literature showed improvements in clinical parameters with all of the periodontal plastic surgery procedures. Randomized controlled trials are needed to identify the indications for each surgical technique and any prognostic factors.

For citation purposes, the electronic version is the definitive version of this article: www.cda-adc.ca/jcda/vol-75/issue-3/203.html

n most adults, the root surfaces of one or more teeth may become exposed through displacement of the gingival margin apical to the cementoenamel junction1 (i.e., gingival recession).2 This problem has various causes: anatomic conditions, including lack of attached gingiva, muscular inserts near the gingival margin, 3,4 poor tooth alignment 5 or inadequate thickness of the alveolar bone plate and root prominences 6

acquired pathological conditions, such as periodontitis7 or viral infection8 iatrogenic factors, such as improper restorations invading the biological space9 mechanical trauma, including trauma associated with toothbrushing10 or lip piercing.11 Gingival recession is a matter of concern for both patients and dental professionals, especially when exposure of the root surface
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is linked to deterioration in esthetic appearance and increase in dental hypersensitivity.11 Traditionally, the primary goals of periodontal therapy are to eliminate any etiologic agents associated with inflammatory disease and to improve clinical parameters, such as clinical attachment level and probing depth. In treating gingival recession, attempts should be made to improve all clinical parameters, especially clinical attachment level and root sensitivity, if present. In a recent cross-sectional survey of specialists in periodontics and general dentists,12 the predominant indication for root-coverage procedures was esthetics (90.7% of respondents). Of the available periodontal plastic surgery (PPS) techniques, free gingival grafting was generally the most favoured option, followed by subepithelial connective tissue grafting (SCTG), coronally advanced flap (CAF) and guided tissue regeneration (with only a small group of the dentists preferring the regeneration procedure). During the past few years, the effectiveness of PPS procedures in the treatment of localized or multiple recession-type defects (MRTD) has been reported in several trials. Studies testing different techniques, such as CAF alone,1316 SCTG alone or in combination with rotated or advanced flaps,1723 and guided tissue regeneration, 2426 have demonstrated that surgical treatment of exposed root surfaces improves clinical attachment levels and reduces gingival recession in most patients. Other recent studies have suggested that the choice of treatment for MRTD involving 2 or more adjacent teeth may be based on a variety of factors, such as anatomic structure, anticipated level of discomfort during healing, cost and need for more than one surgical procedure to treat the entire recession site.22,23 Recent extensive systematic reviews have focused on the effect of PPS procedures in treating localized gingival recession.2733 The authors of these reviews found descriptions of a variety of surgical techniques and flap designs used to correct localized gingival recession, all of which yielded statistically significant improvements in gingival recession and clinical attachment level. The authors also recommended that SCTG, CAF or guided tissue regeneration be used for root coverage in clinical practice. However, these previous reviews2731 had some limitations. For example, they included only Englishlanguage publications. Moreover, some of the reviews2729,31 pooled all sources of evidence available (randomized controlled clinical trials [RCTs], controlled clinical trials and case series), regardless of methodologic quality. Some reviews2831 did not report specific inclusion criteria for types of defect (according to Millers classification34), and some2830 did not report a specific follow-up period. Finally, several of the reviews2730 did not report the use of acellular dermal matrix grafts or enamel matrix protein.
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Of these systematic reviews, 2733 4 included data only up to 2002, 2730 and none focused specifically on PPS procedures in the treatment of MRTD. As such, there is no compilation of evidence-based information for this type of defect. Given the common occurrence of recession areas involving adjacent teeth and the lack of information linking the results achieved to different surgical techniques, the objectives of this systematic review were to evaluate the results obtained with different root-coverage procedures in the treatment of MRTDs and to assess differences in results from RCTs and other types of studies (i.e., degree of concordance in treatment effects between randomized and nonrandomized groups). Materials and Methods Study Selection and Type of Intervention The study protocol used for this review was based on that used for previous publications. 32,33 Studies eligible for inclusion in this review were RCTs, controlled clinical trials and case series involving at least 10 patients per group, with a follow-up period of at least 6 months. Studies had to be limited to patients with a clinical diagnosis of gingival recession affecting adjacent teeth (i.e., recession areas selected for treatment classified as Miller34 Class I or Class II) who underwent PPS procedures (e.g., free gingival grafting; laterally positioned flap; CAF; SCTG, alone or in combination with lateral or advanced flaps; guided tissue regeneration; enamel matrix protein; or acellular dermal matrix grafting). Data from nonrandomized trials were pooled. Trials that reported data for both localized and multiple recession areas were excluded. Outcomes Measures and Search Strategy The outcome measures assessed were changes in gingival recession, clinical attachment level and keratinized tissue, as well as percentage of patients with complete root coverage and mean root coverage. The MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched up to June 2008 with the following MeSH terms, key words and other free terms: GINGIVAL RECESSION [single MeSH term], ((recession NEAR gingiva*) OR (recession NEAR defect*)) OR recession-type defect*, ((exposure NEAR root*) OR (exposed NEAR root*)), (gingiva* NEAR defect*), denude* NEAR root surface*, GUIDED TISSUE REGENERATION [exploded MeSH term], tissue NEAR regenerat*, ((gingiva* NEAR esthetic*) OR (gingiva* NEAR aesthetic*)), periodont* AND plastic surgery, soft tissue graft* OR coronally advanced flap*, laterally positioned flap* OR laterally-positioned flap*, connective tissue graft* OR connective-tissue graft*, gingiva* NEAR transplant*, dermal matrix NEAR graft*,

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enamel matrix protein. Boolean operators (OR, AND) were used to combine searches. Papers published in any language and any journal were considered. The following journals were also searched by hand to include any possible trial not retrieved by electronic search: Journal of Periodontology, Journal of Periodontal Research , Journal of Clinical Periodontology and International Journal of Periodontics and Restorative Dentistry. Assessment of Validity and Methodologic Quality Two independent reviewers (L.C. and L.A.C.) screened the titles, abstracts and full texts of the articles identified by searching. Disagreement between the reviewers was resolved by discussion and consensus. If data were missing, the authors of the original reports were contacted and asked to provide further details. The methodologic quality of the included studies was assessed by consideration of the following points and questions: Method of randomization: (a) adequate, if random number tables, coin toss or shuffled cards were used to assign treatments; (b) inadequate, if any other method was used to assign treatments; (c) unclear, if method of randomization was not reported or explained; or (d) not applicable (i.e., for trials without randomization). Allocation concealment: (a) adequate, if examiners were kept unaware of randomization sequence; (b) inadequate, if allocation was not concealed; (c) unclear, if the method of allocation concealment was not reported or explained; or (d) not applicable (i.e., for trials without randomization). Completeness of the follow-up period (yes/no responses): (a) Were equal numbers of patients present at baseline and follow-up? (b) Were all of the patients who entered the trial properly accounted for at completion? (c) Did the statistical analysis include the total number of patients enrolled in the study? Blinding of examiners with regard to the treatment procedures used in the study period (yes/no response): Were the examiners blinded? In addition, risk of bias was categorized according to the following classification: (a) low risk of bias (i.e., plausible bias that is unlikely to seriously alter the results) if all criteria were met (i.e., adequate methods of randomization and allocation concealment and yes answers to all questions about completeness of follow-up questions and blinding of examiners); (b) moderate risk of bias (i.e., plausible bias that raises some doubt about the results) if one or more criteria were partly met; or (c) high risk of bias (plausible bias that seriously weakens confidence in the results) if one or more criteria were not met.

Results Search Results A total of 632 titles of potentially relevant publications was retrieved from the databases. Of these, 616 articles were excluded after review of the title and abstract. The full texts of the remaining 16 papers were reviewed in more detail. Of these, 4 were considered appropriate for analysis. The other 12 were excluded for the following reasons: fewer than 10 patients per group, 3537 inclusion of patients with Miller34 Class III recession areas, 38,39 data for postsurgical clinical parameters not available or follow-up period less than 6 months,40,41 surgical sites not presenting contiguous recessions (i.e., sites with no recession interposed between teeth with recession),42 inclusion of localized gingival recessions 4345 or duplicate reporting.15 The search strategy was designed to include all types of evidence (RCTs, controlled clinical trials and case series), and one of the study objectives was to compare the results from RCTs with those obtained in nonrandomized trials. However, the search did not yield any RCTs that focused exclusively on the treatment of MRTD. Therefore, only nonrandomized trials were included in the analysis (Table 1). Besides, trials that had incorporated both localized and multiple recession areas were excluded. Quality Assessment For the trials included in the analysis, the numbers of patients at baseline and at final examination were equal, all patients who entered each study were properly accounted for at completion, and the statistical analysis included the total number of patients enrolled. The follow-up periods ranged from 6 to 60 months. However, the studies were not blinded, and none of the publications were randomized or controlled clinical trials. Therefore, all 4 studies were considered to be at high risk of bias. Description of Studies Data regarding changes in probing depth, percentage of root coverage, gain in keratinized gingiva and number of sites with complete coverage are reported in Table 2 . The 4 case series described 4 different surgical procedures: 1 described the use of CAF alone and 3 involved the use of SCTG with CAF. A total of 70 patients were treated in the 4 studies, with the patient being the preferred unit of analysis. Coronally Advanced Flap Only 1 trial was found in which CAF was used for treatment of MRTD. Zucchelli and De Sanctis 47 evaluated the effectiveness of a modified CAF technique for the treatment of MRTD in 22 patients with esthetic demands. At the 12-month follow-up examination, mean root coverage was 97%. Of the 73 maxillary recessions
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Table 1 Characteristics of included studies Study etiner and others 46 Methods 12-month university-based case series: CAF + expanded mesh SCTG 60-month university-based case series: modified CAF Participants and reasons for treatment 10 patients, 2348 years old; reasons not reported Outcomes RD, PD, CAL, KT, CRC, MRC (individual patient data reported) RD, PD, CAL, KT, CRC, MRC (individual patient data reported) RD, PD, CAL, KT, CRC, MRC (individual patient data reported) RD, PD, CAL, KT, CRC, MRC (aggregated patient data reported) Unit of analysis Recession

Zucchelli and De Sanctis 47

22 patients, 1834 years old; esthetics

Patient

Chambrone and Chambrone22

6-month practice-based case series: CAF + SCTG for maxillary versus mandibular sites, with tetracycline 6-month university-based case series: modified CAF + SCTG

28 patients, 1834 years old; esthetics and dental hypersensitivity

Patient

Carvalho and others23

10 patients, 2436 years old; reasons not reported

Patient

Note: CAF = coronally advanced flap, SCTG = subepithelial connective tissue graft, RD = recession depth, PD = probing depth, CAL = clinical attachment level, KT = keratinized tissue, CRC = complete root coverage, MRC = mean root coverage.

present at baseline, 64 (88%) were completely covered, and complete root coverage was achieved in 16 (73%) of the 22 patients. At the 60-month follow-up evaluation, 94% of the exposed root surfaces were still covered with soft tissues, and 15 (68%) of the 22 patients had complete root coverage. SCTG with Coronally Advanced Flap The other 3 studies analyzed in this review evaluated the use of SCTG in association with CAF. The first of these studies 46 assessed the effectiveness of expanded-mesh SCTG in association with CAF. Complete root coverage was achieved for 12 (80%) of 15 treated areas (in a total of 10 patients), with mean root coverage of 96%. The second publication 22 evaluated clinical results obtained with SCTG placed under a CAF for the treatment of MRTD in a sample of 28 patients, 14 of whom had maxillary sites of recession and 14 of whom had mandibular sites. Mean root coverage from baseline to 6 months after surgery was 96%, and complete root coverage was achieved in 20 (71%) of the patients. This study had one distinct difference from the other case series included in this review it was the only study that considered maxillary and mandibular recession defects separately: improvements in gingival recession were significantly better for patients with maxillary MRTDs than for those with mandibular MRTDs. Moreover, mean root coverage was 94% for the mandibular sites and 98% for the maxil203c

lary sites, and the percentage of sites with complete root coverage was 57% (8/14) and 85% (12/14), respectively. The third trial 23 reported the effectiveness and predictability of root coverage at adjacent sites of multiple gingival recessions using a modified coronally advanced flap15 associated with an SCTG in a sample of 10 nonsmoking patients. The authors observed that this combination of techniques was effective and produced predictable root coverage in shallow defects (mean root coverage of 98% and complete root coverage in 90% of patients). Data Analysis and Clinical Outcomes Given the small number of publications and the heterogeneity of procedures reported (i.e., differences in flap design and type of grafting), the study characteristics were considered too variable to allow data to be combined for meta-analysis. Therefore, the data from the 4 studies22,23,46,47 were tabulated (Table 2), and the results considered in terms of mean values. Overall, mean recession ( standard deviation) declined from 2.95 0.36 mm at baseline to 0.13 0.03 mm at final examination. Complete root coverage was achieved in 44 (73%) of the 60 patients (from 3 studies22,23,47) with multiple gingival recessions. Overall mean root coverage at the final examination was 96%. Clinical attachment level decreased from 4.37 0.32 mm at baseline to 1.49 0.18 mm at the final examination, and probing depth decreased from 1.45 0.16 mm to 1.31 0.20 mm. Mean width of keratinized tissue increased from 2.43 0.52 mm at baseline to 3.94 0.41 mm at the final examination.

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Table 2 Changes in various outcomes from baseline to final measurement Mean measurement (SD) Recession depth (mm) Probing depth (mm) Clinical attachment level (mm) Keratinized tissue (mm) Mean root coverage (%) 96 3.11 (0.80) 0.11 (0.27) 1.38 (0.52) 1.13 (0.35) 4.40 (0.86) 1.18 (0.35) 3.93 (0.72) 5.11 (0.76) 94 2.78 (1.13) 0.22 (0.56) 1.06 (0.26) 1.07 (0.26) 3.84 (1.20) 1.29 (0.59) 1.80 (0.86) 3.18 (0.53) 96 3.84 (1.50) 0.14 (0.23) 1.52 (0.47) 1.12 (0.43) 5.29 (1.30) 1.52 (0.47) 1.66 (1.09) 3.82 (0.91) 98 2.10 (0.82) 0.07 (0.26) 2.95 (0.36) 0.13 (0.03) 1.86 (0.74) 1.93 (0.37) 1.45 (0.16) 1.31 (0.20) 3.97 (1.02) 2.00 (0.46) 4.37 (0.32) 1.49 (0.18) 2.34 (1.47) 3.65 (0.94) 96 2.43 (0.52) 3.94 (0.41) 73 (44/60) 90 (9/10) 71 (20/28) 68 (15/22) % of patients with complete root coveragea Not reportedb

Study etiner and others 46 Baseline Final Zucchelli and De Sanctis 47 Baseline Final Chambrone and Chambrone22 Baseline Final Carvalho and others23 Baseline Final Overall Baseline Final

SD = standard deviation. a With raw data in parenthesis. b This study described treatment of 15 sites in 10 patients, and complete root coverage was achieved for 12 (80%) of these 15 sites.

Discussion Several surgical procedures to correct mucogingival problems and improve the esthetics of the patients smile have been described in the dental literature. The 4 studies included in this review22,23,46,47 recorded statistically significant improvements for all clinical parameters except probing depth (Table 2). The best results were achieved by Carvalho and others, 23 but that study (along with the study by etiner and others 46), involved the smallest number of patients (n = 10). Data from a variety of PPS procedures reviewed by other authors12 showed root coverage ranging from 60% to 84% in the treatment of localized gingival recessions. In the systematic review reported here, mean root coverage ranged from 94% to 98%, and complete root coverage ranged from 68% to 90% of patients. Reporting of initial recession depth from all treated sites has been recommended by Bouchard and others 48 but was available in only 3 of the trials analyzed here. 22,46,47 Although 3 of the studies were conducted in a university setting and the fourth was conducted in a private periodontal practice,

electronic probes and probing acrylic stents were not used in any of the trials. All of the studies included in this analysis had a small number of patients, and each tested only one PPS procedure (i.e., no control group). Moreover, no 2 studies used the same surgical procedure. These differences among the studies may be explained by the difficulty in recruiting patients with similar defects or bilateral MRTD sites. Because of the limited number of studies and the lack of RCTs comparing different techniques, it is difficult to recommend a particular PPS procedure for the treatment of MRTD, and it is impossible to draw conclusions about the superiority of one PPS procedure over the others. The secondary objective of this review was to compare the results achieved in RCTs with those obtained in controlled clinical trials and case series, but no RCTs were identified and this comparison could not be performed. Case series have serious methodologic flaws, and their inclusion in a systematic review leads to very weak evidence and adds little to general knowledge of a problem. The fact that none of the studies identified for this study used
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blinded assessment further undermines the strength of the evidence. As such, the greatest strength of the current paper is its role in calling attention to the paucity of welldesigned studies that properly evaluate PPS procedures for the treatment of MRTD. These results also emphasize that RCTs are needed to identify the indications for each surgical technique and their prognostic factors. Two of the studies identified in this review did not include smokers.22,23 Although mean root coverage and percent of patients with complete root coverage were similar for trials with and without smokers (Table 2), cigarette smoking has been reported to affect the short- and longterm outcome of PPS procedures.49 The patients smoking status should therefore be carefully evaluated if surgical correction of gingival recession is being considered.4951 In 1 study, all treated surfaces were conditioned with tetracycline solution during preparation of the site, which is a form of root demineralization.22 The results achieved with such root demineralization have been controversial. Exposed root surfaces have been treated with a solution of citric acid and tetracycline HCl to enhance the degree of attachment of new connective tissue to previously denuded root surfaces through exposure of collagen fibrils of the cementum or dentin between the root surface and the transplanted graft.5255 In contrast, some RCTs have suggested no significant clinical benefit of root conditioning in conjunction with root-coverage procedures. 5658 In all 4 trials, patient selection was based on esthetic considerations or dental hypersensitivity (or both), and treatment was intended to prevent continuing development of gingival recession, root abrasion or root caries and to improve hygiene (Table 1). This information suggests that patients concerns should be carefully evaluated before any surgical correction is planned, with particular attention to whether it is possible to achieve the patients desires with the proposed treatment modality. Consequently, before performing any PPS procedure, the dental professional should select the most appropriate technique for each defect, to ensure that patients individual needs and complaints are addressed and to achieve the best esthetic and functional results. The selection of one PPS procedure rather than another for the treatment of MRTD depends on a variety of factors, such as size of the defect (length and width), width of keratinized tissue adjacent to the defect, number of adjacent teeth to be treated, amount of connective tissue available from the donor site, location of the MRTD (mandibular or maxillary), depth of the vestibular fornix and mucogingival phenotypes.19,22 Insufficient studies are available to allow evaluation of the different PPS procedures, and welldesigned RCTs are needed to address these questions. The Consolidated Standards of Reporting Trials (CONSORT) guidelines59,60 provide guidance on the appropriate design and reporting of clinical trials, to ensure that readers understand the design, conduct, analysis
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and interpretation of trials and can assess the validity of their results. The CONSORT guidelines improve the transparency and quality of reporting of RCTs.60 Conclusions Only limited information about the use of PPS for MRTD is available in the dental literature. Systematic review of this information led to the following conclusions: All of the PPS procedures evaluated (i.e., CAF alone or in combination with SCTG) led to improvements in recession depth, clinical attachment level and width of keratinized tissue. RCTs are needed to identify the indications for each surgical technique and possible prognostic factors. The design and reporting of future studies should take into account the requirements of the CONSORT statements. Patients individual needs should be carefully evaluated before surgical correction of MRTD is planned, to ensure that their chief complaints can be resolved. This review also yielded some general recommendations: If MRTDs involve 2 or more teeth, each surgical site should be considered as a single unit, in terms of determining the extent of complete root coverage (i.e., 100% root coverage is recorded only if all adjacent teeth have adequate root coverage). Multicentre studies may be required to increase the number of patients and to achieve adequate statistical power. a THE AUTHORS
Dr. L. Chambrone is a graduate student, division of periodontics, department of stomatology, School of Dentistry, University of So Paulo, So Paulo, Brazil. Dr. Lima is an associate professor, division of periodontics, department of stomatology, School of Dentistry, University of So Paulo, So Paulo, Brazil. Dr. Pustiglione is a professor and chair of the division of periodontics, department of stomatology, School of Dentistry, University of So Paulo, So Paulo, Brazil. Dr. L.A. Chambrone is a professor and chair of the discipline of periodontics, faculty of dentistry, Methodist University of So Paulo, So Bernardo do Campo, Brazil. Acknowledgements: This paper was reviewed by members of the Cochrane Oral Health Group. Correspondence to: Dr. Leandro Chambrone, Disciplina de Periodontia, Departamento de Estomatologia, Faculdade de Odontologia, Universidade de So Paulo Av. Prof. Lineu Prestes, 2227 Cidade Universitria, 05508000 So Paulo SP. The authors have no declared financial interests. This article has been peer reviewed.

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References
1. American Academy of Periodontology. Glossary of periodontal terms. 4th ed. Chicago: American Academy of Periodontology; 2001. 2. Susin C, Haas AN, Oppermann RV, Haugejorden O, Albandar JM. Gingival recession: epidemiology and risk indicators in a representative urban Brazilian population. J Periodontol 2004; 75(10):137786. 3. Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994; 14(2):12637. 4. Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontol 2000 2001; 27:7296. 5. Stoner J, Mazdyasna S. Gingival recession in the lower incisor region of 15-year-old subjects. J Periodontol 1980; 51(2):746. 6. Wennstrm JL, Zucchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996; 23(8):7707. 7. Yoneyama T, Okamoto H, Lindhe J. Sockransky SS, Haffajee AD. Probing depth, attachment loss and gingival recession. Finding from a clinical examination in Ushiku, Japan. J Clin Periodontol 1988; 15(1):58191. 8. Prato GP, Rotundo R, Magnani C, Ficarra G. Viral etiology of gingival recession. A case report. J Periodontol 2002; 73(1):1104. 9. Parma-Benfenali S, Fugazzoto PA, Ruben MP. The effect of restorative margins on the postsurgical development and nature of the periodontium. Part I. Int J Periodontics Restorative Dent 1985; 5(6):3051. 10. Khocht A, Simon G, Person P, Denepitiya JL. Gingival recession in relation to history of hard toothbrush use. J Periodontol 1993; 64(9):9005. 11. Chambrone L, Chambrone LA. Gingival recessions caused by lip piercing: case report. J Can Dent Assoc 2003; 69(2):5058. 12. Zaher CA, Hachem J, Puhan MA, Mombelli A. Interest in periodontology and preferences for treatment of localized gingival recessions. J Clin Periodontol 2005; 32(4):37582. 13. Trombelli L, Scabbia A, Wikesj UM, Calura G. Fibrin glue application in conjunction with tetracycline root conditioning and coronally positioned flap procedure in the treatment of human gingival recession defects. J Clin Periodontol 1996; 23(9):8617. 14. Modica F, Del Pizzo M, Roccuzzo M, Romagnoli R. Coronally advanced flap for the treatment of buccal gingival recessions with and without enamel matrix derivative. A split-mouth study. J Periodontol 2000; 71(11):16938. 15. Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000; 71(9):150614. 16. Pini Prato GP, Baldi C, Nieri M, Franseschi D, Cortellini P, Clauser C, and others. Coronally advanced flap: the post-surgical position of the gingival margin is an important factor for achieving complete root coverage. J Periodontol 2005; 76(5):71322. 17. Harris HJ. The connective tissue with partial thickness double pedicle graft: the results of 100 consecutively-treated defects. J Periodontol 1994; 65(5):44861. 18. Bouchard P, Etienne D, Ouhayoun JP, Nilvus R. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures. J Periodontol 1994; 65(10):92936. 19. Caffesse RG, De LaRosa M, Garza M, Munne-Travers A, Mondragon JC, Weltman R. Citric acid demineralization and subepithelial connective tissue grafts. J Periodontol 2000; 71(4):56872. 20. Vergara JA, Caffesse RG. Localized gingival recessions treated with the original envelope technique: a report of 50 consecutive patients . J Periodontol 2004; 75(10):1397403. 21. Lee YM, Kim JY, Seol YJ, Lee YK, Ku Y, Rhyu IC, and others. A 3-year longitudinal evaluation of subpedicle free connective tissue graft for gingival recession coverage. J Periodontol 2002; 73(12):14128. 22. Chambrone LA, Chambrone L. Subepithelial connective tissue grafts in the treatment of multiple recession-type defects. J Periodontol 2006; 77(5):90916. 23. Carvalho PF, da Silva RC, Cury PR, Joly JC. Modified coronally advanced flap associated with a subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions. J Periodontol 2006; 77(11):19016. 24. Prato GP, Clauser C, Magnani C, Cortellini P. Resorbable membranes in the treatment of human buccal recession: a nine-case report. Int J Periodontics Restorative Dent 1995; 15(3):25867. 25. Tatakis DN, Trombelli L. Gingival recession treatment: guided tissue regeneration with bioabsorbable membrane versus connective tissue graft. J Periodontol 2000; 71(2):299307. 26. Leknes KN, Amarante ES, Price DE, Boe OE, Skavland RJ, Lie T. Coronally positioned flap procedures with or without a biodegradable membrane

in the treatment of human gingival recession. A 6-year follow-up study. J Clin Periodontol 2005; 32(5):51829. 27. Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: a systematic review. J Clin Periodontol 2002; 29 Suppl 3:17894. 28. Pagliaro U, Nieri M, Franceschi D, Clauser C, Pini-Prato G. Evidencebased mucogingival therapy. Part 1: A critical review of the literature on root coverage procedures. J Periodontol 2003; 74(5):70940. 29. Clauser C, Nieri M, Franceschi D, Pagliaro U, Pini-Prato G. Evidence-based mucogingival therapy. Part 2: Ordinary and individual patient data meta-analyses of surgical treatment of recession using complete root coverage as the outcome variable. J Periodontol 2003; 74(5):74156. 30. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol 2003; 8(1):30320. 31. Hwang D, Wang HL. Flap thickness as a predictor of root coverage: a systematic review. J Periodontol 2006; 77(10):162534. 32. Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? J Dent 2008; 36(9):65971. 33. Chambrone L, Sukekava F, Araujo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root coverage procedures for the treatment of localised recessiontype defects. Cochrane Database Syst Rev 2009; Issue 2. In press. 34. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985; 5(2):813. 35. Tzm TF, Dini FM. Treatment of adjacent gingival recessions with subepithelial connective tissue grafts and the modified tunnel technique. Quintessence Int 2003; 34(1):713. 36. Haghighat K. Modified semilunar coronally advanced flap. J Periodontol 2006; 77(7):127479. 37. Dembowska E, Drozdzik A. Subepithelial connective tissue graft in the treatment of multiple gingival recession. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104(3):e17. 38. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: a clinical report. Int J Periodontics Restorative Dent 1999; 19(12):199206. 39. Blanes RJ, Allen EP. The bilateral pedicle flap-tunnel technique: a new approach to cover connective tissue grafts. Int J Periodontics Restorative Dent 1999; 19(5):4719. 40. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent 1994; 14(3):21627. 41. Harris RJ, Miller LH, Harris CR, Miller RJ. A comparison of three techniques to obtain root coverage on mandibular incisors. J Periodontol 2005; 76(10):175867. 42. Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ, and others. Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol 2001; 72(5):57182. 43. Tzm TF, Keeli HG, Gnc GN, Hatipoglu H, Sengun D. Treatment of gingival recession: comparison of two techniques of subepithelial connective tissue graft. J Periodontol 2 005; 76(11):18428. 44. Santos A, Goumenos G, Pascual A. Management of gingival recession by the use of an acellular dermal graft material: a 12-case series. J Periodontol 2005; 76(11):198290. 45. Gupta R, Pandit N, Sharma M. Clinical evaluation of a bioresorbable membrane (polyglactin 910) in the treatment of Miller type II gingival recession. Int J Periodontics Restorative Dent 2006; 26(3):2717. 46. etiner D, Bodur A, Uraz A. Expanded mesh connective graft for the treatment of multiple gingival recessions. J Periodontol 2004; 75(8):116772. 47. Zucchelli G, De Sanctis M. Long-term outcome following treatment of multiple Miller class I and II recession defects in esthetic areas of the mouth. J Periodontol 2005; 76(12):228692. 48. Bouchard P, Malet J, Borguetti A. Decision-making in aesthetics: root coverage revisited. Periodontol 2000 2001; 27:97120. 49. Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. The influence of tobacco smoking on the outcomes achieved by root coverageprocedures: a systematic review. J Am Dent Assoc 2009; 140(3):294306. 50. Trombelli L, Scabbia A. Healing response of gingival recession defects following guided tissue regeneration procedures in smokers and nonsmokers. J Clin Periodontol 1997; 24(8):52933. 203f

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51. Martins AG, Andia DC, Sallum AW, Sallum EA, Casati MZ, Nociti Jnior FH. Smoking may affect root coverage outcome: a prospective clinical study in humans. J Periodontol 2004; 75(4):58691. 52. Trombelli L, Scabbia A, Zangari F, Griselli A, Wikesj UM, Calura G. Effect of tetracycline HCl on periodontally-affected human root surfaces. J Periodontol 1995; 66(8):68591. 53. Madison JG 3rd, Hokett SD. The effects of different tetracyclines on the dentin root surface of instrumented, periodontally involved human teeth: a comparative scanning electron microscope study. J Periodontol 1997; 68(8):73945. 54. Bergenholtz A, Babay N. Scanning electron microscopy of the root surface texture of extracted periodontally diseased teeth following various etching and chelating regimens. Int J Periodontics Restorative Dent 1998; 18(2):1719. 55. Isik AG, Tarim B, Hafez AA, Yalcin FS, Onan U, Cox CF. A comparative scanning electron microscopic study on the characteristics of demineralized dentin root surface using different tetracycline HCl concentrations and application times. J Periodontol 2000; 71(2):21925. 56. Bouchard P, Etienne D, Ouhayoun JP, Nilvus R. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures. J Periodontol 1994; 65(10):92936. 57. Bouchard P, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl conditioning in the treatment of gingival recessions. A comparative study. J Periodontol 1997; 68(3):2629. 58. Caffesse RG, De LaRosa M, Garza M, Munne-Travers A, Mondragon, JC, Weltman R. Citric acid demineralization and subepithelial connective tissue grafts. J Periodontol 2000; 71(4):56872. 59. Consolidated Standards of Reporting Trials (CONSORT). CONSORT Statement. 2007 Oct 22. Available: www.consort-statement.org/index. aspx?o=1011. 60. Needleman I, Worthington H, Moher D, Schulz D, Altman DG. Improving the completeness and transparency of reports of randomized trials in oral health: The CONSORT Statement. Am J Dent 2008; 21(1):712.

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